905 - Unmasking a Stroke Mimic: Brachial Plexus Hematoma in an Elderly Patient with Focal Deficits

Thursday, February 19, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

EC

Enrique Cruz, MD

Resident
Westchester Medical Center
Caguas, Puerto Rico, United States

Co-Author(s)

DF

Daniel Furhang, MD

medical student
New York Medical College
Valhalla, New York, United States

Corresponding Author(s)

JS

Jordan Stumph, MD

Attending physician
Westchester Medical Center
Valhalla, New York, United States

Submitter(s)

EC

Enrique Cruz, MD

Westchester Medical Center
Caguas, Puerto Rico, United States

Case Diagnosis: Traumatic right axillary hematoma with brachial plexus involvement, mimicking acute ischemic stroke.

Case Description: A 92-year-old right-handed male with significant cardiovascular and musculoskeletal comorbidities presented with acute right upper extremity (RUE) weakness following a mechanical fall, without preceding neurological symptoms. Initial evaluation concerning for stroke (NIHSS 6 for RUE paralysis), but imaging revealed no acute infarct or large vessel occlusion. MRI of brachial plexus revealed a right axillary mass, confirmed as a hematoma on CTA. Cervical spine imaging showed degenerative stenosis without acute findings. Physical exam showed complete flaccid paralysis (0/5) in the RUE with edema, sensory loss, and shoulder pain. Surgery deferred intervention, and conservative management was pursued. Initial rehabilitation focused on edema control, joint support (ultra-sling), and passive range of motion to preserve mobility and manage pain.

Discussions: This case underscores the importance of differentiating stroke mimics in elderly patients presenting with sudden focal deficits. The flaccid RUE paralysis, absence of cortical findings, and negative imaging for acute cerebral infarction raised concern for a peripheral cause. The traumatic axillary hematoma was likely due to soft tissue injury from the fall, with secondary compression of the brachial plexus. Clinical features like focal swelling, pain, and absence of spasticity supported a peripheral rather than central etiology. Early involvement of physical and occupational therapy was vital to support functional independence and ADL performance.

Conclusions:
Traumatic hematoma with brachial plexus involvement can mimic acute ischemic stroke, particularly in elderly patients with falls and comorbidities. Early recognition prevents unnecessary interventions and guides proper management. In this case, conservative treatment and rehabilitation supported gradual recovery, with minimal motor return (1/5 elbow flexion) showing therapy potential. An interdisciplinary approach and early rehab were key to optimizing outcomes in complex peripheral nerve injuries.